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Establish a Culture of Safety: Working Toward Zero Surgical Site Infections

Establish a Culture of Safety: Working Toward Zero Surgical Site Infections. Maureen Spencer, RN, M.Ed, CIC Infection Preventionist Consultant. Email: maureen_spncr@yahoo.com www.workingtowardzero.com www.creativehandhygiene.com.

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Establish a Culture of Safety: Working Toward Zero Surgical Site Infections

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  1. Establish a Culture of Safety:Working Toward Zero Surgical Site Infections Maureen Spencer, RN, M.Ed, CIC Infection Preventionist Consultant Email: maureen_spncr@yahoo.com www.workingtowardzero.com www.creativehandhygiene.com

  2. Despite current preventive measures, SSIs remain a significant problem • WHO Guidelines for Safe Surgery 2009. • Cheadle WG. Risk factors for surgical site infection. Surg Infect. 2006;7: s7-s11. • In the US, at least 780,000 SSIs occur each year1 • SSIs account for about 37% of all hospital-acquired infections for surgical patients1 • SSIs occur in up to 5% of surgical patients2

  3. Mortality risk is high among patients with SSIs • A patient with an SSI is: • 5x more likely to be readmitted after discharge1 • 2x more likely to spend time in intensive care1 • 2x more likely to die after surgery1 • The mortality risk is higher when SSI is due to MRSA • A patient with MRSA is 12x more likely to die after surgery2 • WHO Guidelines for Safe Surgery 2009. • Engemann JJ et al. Clin Infect Dis. 2003;36:592-598.

  4. SSIs are costly and are a financialburden on the healthcare system • Scott RD. Centers for Disease Control and Prevention. March 2009. • Anderson DJ et al. PLoS One. 2009 Dec 15;4(12):e8305. The average cost of treating one SSI is between $11,000 and $35,0001 The average cost of treating one MRSA-related SSI is more than $60,0002 In total, SSIs have been estimated to cost the US healthcare system up to $10 billion/yr1

  5. Changing demographics are increasing patients’ risk for SSIs • Mangram AJ et al. Am J Infect Control Hosp Epidemiol. 1999;27:97-134. • SHEA, APIC, CDC, SIS Consensus paper. Infect Control Hosp Epidemiol 1992;13:599-605. • Cheadle WG. Surg Infect. 2006;7: s7-s11. • Konishi T, Watanabe T, Kishimoto J, Nagawa H. Ann Surg. 2006 Nov;244(5):758-63. • A patient with even ONE of these risk factors is at greater risk of developing an SSI.1-4 • Older (>70 yrs old) • Obese (BMI > 25) • Smoker • Diabetes or poor glucose control • Undergoing abdominal surgery • Prolonged surgery required (>2 hrs) • Longer hospital stay • ≥3 discharge diagnoses

  6. 6 SSI Risk Factors – Procedures/Techniques • Duration of operation • Duration of surgical scrub • Preoperative shaving, skin preparation • Inadequate OR ventilation • Inadequate sterilization of instruments • Surgical technique • Poor hemostasis • Failure to obliterate dead space • Tissue trauma • Skin antisepsis • Antimicrobial prophylaxis • Surgical drains Tissue kept moist with saline Tissue allowed to air dry heals better do not heal as well Mangram AJ et al. Am J Infect Control. 1999;27:97-134

  7. Orthopedic Surgical Site Infection Orthopedic Total Joint Infections: Hip or Knee aspiration If positive – irrigation and debridement Removal of hardware may be necessary Insertion of antibiotic spacers Revisions at future date Long term IV antibiotics in community or rehab Future worry about the joint In other words – DEVASTATING FOR THE PATIENT AND THE SURGEON 8

  8. Relative Economic Burden Associated with HAIs Est. Annual # of Infections Direct Cost per Patient (2007$) Avg. Increased Length of Stay Attributable Mortality 4% 26% 24% 1%~4% ~12 days ~10-24 days ~9-13 days 1 day~9.1 days • SSISurgical Site Infections • CLA-BSICentral-Line Associated Blood Stream Infections • VAPVentilator Associated Pneumonia • CA-UTICatheter-Associated Urinary Tract Infections • Other / MDROs*Multi-Drug Resistant Organisms (e.g., MRSA, C. difficile, VRE, etc.) $34,670 $29,156 $28,508 $1,007~$30,000 290,485(~17% of HAIs) 248,678(~14% of HAIs) 250,205(~15% of HAIs) 561,667(~32% of HAIs) 386,090 (~22% of HAIs) * NOTE: MDRO often cause other infection types (e.g., SSI, BSI, VAP, UTI); MDRO statistics reflect CDC estimates for methicillin-resistant Staphylococcus aureus (MRSA) only.SOURCES: Klevens, et al., “Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002,” Public Health Review, 2007; CDC: “The Direct Medical Cost of HAIs in U.S. Hospitals and the Benefits of Prevention”, March 2009; Kirkland, et al., “The Impact of Surgical Site Infections”, Infect Control Hosp Epidemiol, 1999; Arch Internal Med, 1988; Arch Internal Med, 1974; Infect Control Hosp Epidemiol, 2002; CareFusion MedMined Analysis, 2009. 9

  9. Pathogens survive on surfaces 1. Beard-Pegler et al. 1988.. J Med Microbiol. 26:251-5. 2. BIOQUELL trials, unpublished data. 3. Bonilla et al. 1996. Infect Cont Hosp Epidemiol. 17:770-2 4. Boyce. 2007. J Hosp Infect.65:50-4. 5. Duckworth and Jordens. 1990. J Med Microbiol. 32:195-200. 6. French et al. 2004. ICAAC. 7. Kramer et al. 2006. BMC Infect Dis. 6:130. 8. Otter and French. 2009. J ClinMicrobiol. 47:205-7. 9. Smith et al. 1996. J Med. 27: 293-302. 10. Wagenvoort et al. 2000. J Hosp Infect. 45:231-4. 11. Wagenvoort and Joosten. 2002. J Hosp Infect. 52:226-7.

  10. Why Better Environmental Cleaning?Prior room occupancy increases risk 1. Martinez et al. Arch Intern Med 2003; 163: 1905-12. 2. Huang et al. Arch Intern Med 2006; 166: 1945-51. 3. Dreeset al. Clin Infect Dis2008; 46: 678-85. 4. Shaughnessy. ICAAC/IDSA 2008. Abstract K-4194. 5. Nseir et al. ClinMicrobiol Infect 2010 (in press).

  11. 150-bed adult medical/surgical hospital located in Mission Hill area of Boston Orthopaedic subspecialty hospital & “Center of Excellence” Acute inpatient discharges: 75% Orthopedic 8% General Surgery 17% Medical Orthopaedic Surgery ~ 12,000/cases a year >4700 total joints >1500 spine >3600 other (foot, shoulder, etc) > 3100 outpatient New England Baptist HospitalBoston, MAWorking Toward Zero Teams

  12. Antibacterial sutures MRSA/MSSA Eradication Program Chloroprep Instituted incisional adhesives and AMD Gauze Increase in Lami infections due to locally administered steroids Increase in total knee infections – due to improper use of needles for OR pain meds Post-op hematomas being investigated

  13. Making the Case to Cover Incisions While Hospitalized

  14. Post-op Skin Issues in Orthopedics Anterior fusion with tape burns Contaminated steri-strips Posterior fusion with contaminated steri-strips Staples increase infection rate

  15. Obesity and Surgical Incision • Incision collects fluid – serum, blood - growth medium for organisms • Spine fusions -incisions close to the buttocks or neck • Heavy perspiration common • Body fluid contamination from bedpans/commodes • Friction and sliding - skin tears and blisters • Itchy skin - due to pain medications - skin breakdown

  16. Due to Environmental Contaminants – Do Not Recommend Incisions Opened to Air Bacteria use blood (and sugar) as a fuel source Incisions are in exudative stage of wound healing first 2-3 days postop Proliferative stage begins ~ day 3-4 and most patients are sent home around that time Incisions are best protected if sealed – or covered with an antimicrobial gauze, silver dressing

  17. Resident and PA Direct Observation Study: ABD with Paper or Gauze Tape Check residents and physician assistant dressing technique ABD pads may be stuffed in lab coat pockets during rounds and gloves may not be worn for dressing changes Lack of hand hygiene before and after patient contact Bandage scissors often used between patients with no cleaning Discard bloody dressings in regular waste

  18. Facility Approach: Standardization to an Antimicrobial Dressing (AMD) AMD secured with MeFix tape and dated for protection from exogenous contamination

  19. Standardization of Post-operative Dressings

  20. Goal • Primary goal is to cover all incisions with AMD gauze dressing (antimicrobial) • Leave primary dressing in place for at least 2 days post-op or until the day of discharge to create an occlusive environment for wound healing • Nursing staff will assume responsibility for dressing changes, assessments, and reporting of complications to MD, PA, or NP

  21. Initial Dressing Change • Will be completed as specified on the orthopedic order sheet • Example: POD # 2 • Preferably dressing would be left in place until day of discharge • Exception: Significant strike through (post-op drainage) • Alert the MD, PA, NP • Initially reinforce and change dressing in 24 hrs

  22. Subsequent Dressing Changes • On the morning of discharge change the dressing and record the condition of the incision in the progress notes • Notify the Attending MD if available or resident, PA, or NP of any significant findings

  23. Report Significant Findings • Notify the Attending MD: • Evidence of wound dehiscence • Drainage • Sanguinous and Purulent drainage • Moderate or Copious amount of drainage • Incisional Complication • Blisters • Erythema • Edema • Skin Tears • Warmth • Ecchymosis • Incisional Breakdown

  24. Postop Dressing Care • Sanitize hands • Wear clean gloves to remove primary dressing • Sanitize bandage scissors with alcohol between use • Discard old dressing in red bag if saturated and dispose in soiled utility room • Apply a sterile dressing using Kendall’s AMD gauze (antimicrobial dressing – purple package) • Affix gauze with MeFix tape (hypoallergenic self-adhesive fabric tape), Tegaderm, or Ace Wrap as appropriate

  25. MeFix Tape • Pull the sides of the tape to break open the backing • Remove one side all the way down the piece of tape • Tape one side of the gauze and then the other • Do not stretch as you apply to prevent blisters

  26. Hip Dressing Typically the original dressing will be covered with either Microfoam or Tegaderm Microfoam dressing Tegaderm dressing

  27. Dressing Treatments • Hip Incisions • Apply 2 - 4 AMD Gauze Over Incision • Loosely secure with MeFix tape to allow for swelling • Date and initial the dressing • If dressing is removed for a brief inspection it may be re-secured in place • If dressing removed entirely by surgeon or other – reapply as soon as possible

  28. Dressing Treatments • Knee Incisions • AMD gauze directly over incision • 6 inch Ace wrap dressing • Applied distal to proximal and should extend to mid-thigh level above any suprapatellar pouch swelling to avoid a tourniquet affect just above the knee

  29. Spine Service and Shoulders AMD Island dressing – left on until discharge AMD sealed with Tegaderm left on until discharge Rotator cuff (and total shoulders) – Dermabond is being used or an AMD gauze covered by tegaderm – left on until discharge

  30. Strike Through • Minimal strike-through drainage • Leave dressing intact • Change dressing as indicated on orders • Significant strike-through drainage • Notify MD, PA, or NP and reinforce unless otherwise ordered • Change dressing on Post-op Day1

  31. Documentation: • Daily Skin Assessment in Meditech • Location • Description • Drainage • Periphery • Wound Edges • Amount of Exudate • Type of Exudate • Nursing Intervention • Comment: Incisional Complications • Progress Notes for any complications • Specify who was notified and when • Specify treatment and plan for any incisional complications

  32. Discharge Dressings • Hip, Knee, Spine, and Shoulder Discharge Dressings • Apply same dressing used in the hospital • Wounds Without Drainage • Patient should be instructed to remove the dressing after 2 days. It can then be left open to air. • Once the dressing has been removed, the patient may shower after the 2 days but should be instructed not to use washcloths or scrub the incision with any soap. • Wounds With Drainage • VNA services required at home • Dressings may vary depending on amount of drainage • Wounds with Sutures or Staples • Should be kept covered until the sutures or staples are removed

  33. Cost Savings • Discharge Supplies • Patients with Sutures or Staples: • Supply patient with 2 additional dressing changes at home • Shower drapes: (for patients without Tegaderm) • 2 per patient or more if appropriate • They can be cut in half • Patients with Steri Strips • Unless draining, patient will not need any supplies for home

  34. Questions?

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